Provider Demographics
NPI:1447210638
Name:SY, MARIO BAUTISTA (MD)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:BAUTISTA
Last Name:SY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1351 KIMBERLY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-4193
Mailing Address - Country:US
Mailing Address - Phone:563-355-7733
Mailing Address - Fax:563-355-9077
Practice Address - Street 1:1351 KIMBERLY RD
Practice Address - Street 2:STE 100
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-4193
Practice Address - Country:US
Practice Address - Phone:563-355-7733
Practice Address - Fax:563-355-9077
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34978174400000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2110700Medicaid
421423259OtherFEDERAL TAX INDENTIFICATI
34565OtherWELLMARK BC BS
G16088Medicare UPIN
IA2110700Medicaid
IA1005990001Medicare NSC